Long Form: Step 1 of 11 - Contact Information 0% Contact InformationName* First Last Email* Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country PhoneAre you female or male?*FemaleMaleAgeBirthdate Health concerns and goalsWhat are your health concerns?check all that apply weight loss healthy eating low energy digestive issues lifestyle change high blood pressure high cholesterol disease prevention skin issues depression anxiety bloating headaches migraines underweight eating disorder Other HeightCurrent weight?What is your weight goal?When was the last time as an adult that you were at your goal weight?What weight have you been the most often in your adult life?What seems like your body's set weight, a place where it seems to have settled most often in the past?Do you have a history of yo-yo dieting?What was your weight one year ago? FoodWhat do you typically eat and drink?BreakfastLunchDinnerSnacksLiquidsWhat are your absolute all-time favorite foods?Do have a special diet (vegan, vegetarian, etc?)No, I eat a variety of foodsYes, I'm vegetarianYes, I'm veganYes, I'm a PescatarianNo, but I try to avoid red meatHow often do you cook? Work & ActivityOccupationHow many hours do you work a week?How active are you at work?No answerExtremelyVeryModeratelyLightlySedentaryHow often do you exercise?No answerTwice a dayOnce a day5-6 days a week4-5 days a week3-4 days a week2-3 days a week1-2 days a week1-3 days a monthI walk a lot but that's about itI don't exerciseDo you play sports?No answerYesNoI used toDo you work out with a trainer?No answerNoYesI used toIf you would like, please explain more about your exercise habits, preferences and/or limitations Lifestyle HabitsAre you in the habit of skipping breakfast?YesNoDo you smoke?If so, how much?How many days a week do you order takeout?No answer10-205-104-62-31-2rarelyneverHow many days a week do you eat out?No answer10-205-104-62-31-2rarelyneverWhat types of places do you typically order from?check all that apply Chinese high-end restaurants Italian Japanese farm to table Thai Middle Eastern sushi vegetarian Ethiopian cafe food Mexican seafood fast food places American health food places Which of these foods do you crave?check all that apply chips ice cream red meat carbs bread soda chocolate salt sugar cereal beer wine cheese I have no cravings other What blood type are you?No answerABA/B0I have no clueHow many alcoholic beverages do you have per week on average?No answer35+20-3010-205-104-62-41-22-4 drinks a monthI don't drinkHow many cups of coffee do you have a day?Do you do any of the following?check all that apply snack too much binge overeat none of the above Do you do get caffeine from any of the following?check all that apply black tea green tea chocolate maté diet soda soda other If you would like, please explain more about your lifestyle habits, preferences and/or limitations. StressHow high are your stress levels?No AnswerExtreme, almost intolerableVery, I have a lot going on right nowModerate, probably the same as most peopleLow, I manage it well when it comes upDo you push really hard if/when doing cardio?No answerYes, I love things like running and spinning and I do it a lotI would if I didn't have stress fractures from exerciseSomewhat, I do intense cardio classes or running 1-3x a weekNot really, I keep it pretty low-impact and my heart rate fairly lowNot at all, I couldn't even imagine running or taking a Zumba classDo you consider yourself an aggressive or type-A person?No answerYesNoMaybe, I'm entirely sureNot at allAny muscle or joint pain/stiffness?please explainHow often do you get irritable?No answerSeems like all of the time lately4-6x a week3-4x a week2-4x a week1-2x a weekrarelyneverHow many hours of sleep do you get a night?No answer10+9-107-85-62-41-2Which of the following mind/body work are you involved with?check all that apply therapy yoga massage acupuncture martial arts other Any serious illnesses, hospitalizations or injuries?please explainDo you have allergies?please explain DigestionDo you suffer from any of the following digestive issues?check all that apply bloating reflux IBS (irritable bowl syndrome) ulcer stomach pain colitis food sensitivities gas constipation diarrhea lactose intolerance celiac disease diverticulitous gall bladder pain gall bladder removal wheat intolerance candida/yeast other SkinDo you suffer from any of the following skin issues?check all that apply serious acne mild acne dry skin rosacea psoriasis boils dandruff fungal infections hives eczema none of the above other Supplements & MedicationsAre you taking Supplements?If so, which ones?Have you been prescribed any medications?(if yes, which ones, reasons for taking and any side effects) HormonesDo you have low testosterone?No answerYesNoDo you suffer from any of the following hormonal symptoms?check all that apply heavy periods irregular periods lack of period PMS-related depression PMS-related anxiety cramping yeast infections PMS-related migraines urinary tract infections peri-menopause symptoms infertility trouble conceiving PMS-related skin flare ups hot flashes low energy chocolate cravings bloating water retention PCOS (Poly-cystic Ovarian Syndrome) Endometriosis fibroids cysts Vulvodynia hair loss unwanted hair growth low libido other Are you pregnant?YesNoAre you planning on getting pregnant in the next year or two?YesNoActively trying now!If you would like, please expand on hormone/pregnancy concerns and goals Additional CommentsHow did you hear about me?*check all that apply Google search Yelp Flyer Psychology Today's practitioner referral website Bing search Yahoo search Yellow pages online A friend referred me BNI My doctor referred me Is there anything else you would like to tell me? Share Facebook Facebook Share Twitter Tweet Google+ Pinterest Email a Friend Email a Friend
